Acute PancreatitisJanuary 29, 2019 & February 5, 2019

Sonia Lin

Etiologies

Presentation

Determining Severity

Complications

Management

MKSAP Question

Cases

ETIOLOGIES

Etiologies

• I Idiopathic

• G Gallstones

• E EtOH

• T Trauma

• S Steroids

• M Mumps

• A Autoimmune

• S Scorpion sting (Trinidad, Tobago)

• H Hypertriglyceridemia (> 1000 mg/dL), Hypercalcemia

• E ERCP

• D Drugs (6-MP, VPA, ACEi, mesalamine, furosemide, HCTZ)

PRESENTATION

Clinical Presentation

Diagnosis (requires 2 of the 3 features):

1. Acute onset upper abdominal pain

• Sudden onset radiating to the back

• Improves with sitting or leaning forward

• Associated with nausea, vomiting, fever

2. Serum amylase or lipase > 3x ULN

3. Characteristic finding on imaging (US or CT or MRI)

• Pancreatic or peripancreatic edema

• Inflammatory stranding

• Fluid collections

• Pancreatic necrosis

DETERMINING SEVERITY

Disease Severity

Mild (80%) Moderate (15-20%) Severe

• Uncomplicated• Reversible• Recovery in

several days

• Local pancreatic complications• Pancreatic necrosis• Acute fluid collections

• Transient organ system failure• Circulatory• Renal• respiratory

• Persistent organ failure > 48 hours

Banks PA, et al. Classification of acute pancreatitis – 2012: revision of Atlanta classification and definitions by international consensus. Gut 2013;62:102-11.

Predictors of Severity

• Clinical factors

• Advanced age (≥ 60)

• Numerous and severe coexisting conditions

• Obesity (BMI > 30)

• Long-term, heavy alcohol use

• Laboratory factors

• Hemoconcentration (↑ Hct)

• Azotemia (↑ BUN & Cr)

• Elevated inflammatory markers

Amylase or lipase

Prognostic Criteria

• Ranson Criteria

• Acute Physiology and Chronic Health Evaluation (APACHE II)

• Atlanta Criteria

• Systemic Inflammatory Response Syndrome Score (SIRS)

• APACHE-O

• Glasgow scoring system

• Harmless Acute Pancreatitis Score (HAPS)

• Japanese Severity Score (JSS)

• Pancreatitis Outcome Prediction (POP)

• Bedside Index for Severity in Acute Pancreatitis (BISAP)

Ranson Criteria

On admission 48 hours into admission

WBC > 16k Hct drop > 10%

Age > 55 BUN increases > 5 mg/dL

Glucose > 200 mg/dL Ca < 8 mg/dL

AST > 250 PO2 < 60 mmHg

LDH > 350 Base deficit (24 – HCO3) > 4 mg/dL

Fluid needs > 6L

Ranson’s score ≥ 3 = severe pancreatitisPoor predictor of severity

APACHE-II Score

APACHE II score ≥ 8 = severe pancreatitis (mortality 11-18%)Poor predictive value at 24 hours

Atlanta Criteria

• Ranson’s Score ≥ 3

• APACHE II score ≥ 8

• Organ failure

• SBP < 90 mmHg

• PaO2 ≤ 60 mmHg

• Cr > 2 mg/dL after hydration

• Systemic complications

• DIC

• Ca ≤ 7.5 mg/dL

• Local complications

• Presence of necrosis, abscess, or pseudocyst

Positive factor = severe pancreatitis

SIRS

Two or more of the following:

• Temp > 38.3°C or < 36.0°C

• HR > 90 beats/minute

• RR > 20 breaths/minute or PaCO2 of < 32 mmHg

• WBC of > 12k, < 4k or > 10% bands

SIRS persisting for > 48 hours is indicative of poor prognosis.

COMPLICATIONS

The Role for CT Imaging

Indications for CT scan:

• High fevers, signs of sepsis

• Severe pancreatitis

• Failure to improve with conservative therapy after 48-72 hours of admission

Why is CT helpful?

• Determining prognosis

• Presence or absence of local complications

• Assessing need for antibiotics

CT Severity Index (CTSI)CT Grade Points Necrosis Score Points

Normal pancreas 0 No necrosis 0

Focal or diffuse enlargement 1 Necrosis of 1/3 of pancreas 2

Intrinsic change; fat stranding 2 Necrosis of 1/2 of pancreas 4

Single, ill-defined collection of fluid

3 Necrosis of > 1/2 of pancreas 6

Multiple collections of fluid or gas in or adjacent to pancreas

4

CTSI > 6 = severe pancreatitis

Pancreatic Necrosis

Generally sterile!

However; consider infectednecrosis in patients who deteriorate or fail to improve after 7-10 days of hospitalization

• CT-guided FNA

• Empiric antibiotics

• Carbapenems, quinolones, metronidazole

http://www.radiologyassistant.nl/en/p550455dae5806/pancreas-acute-pancreatitis-20.html

Who Goes to the ICU?

• APACHE II score > 8 in the first 24 hours of admission

• > 48 hours SIRS

• Hct > 44%, BUN > 20 mg/dL, or Cr > 1.8 mg/dL

• Age > 60

• Underlying cardiac or pulmonary disease, obesity

MANAGEMENT

Management

• IV fluids

• Pain control

• Bowel rest → Feeding

• Antibiotics

• ERCP

• Surgical Interventions

IV Fluids

Aggressive fluid administration within 24 hours reduces morbidity and mortality!

• MOST important in the first 12-24 hours after symptom onset

• Of little value after 24 hours

What: Isotonic crystalloid (NS or LR)

• Avoid LR in patients with acute pancreatitis 2/2 hypercalcemia

Rate: 5-10 mL/kg/hr (~ 250-500 mL/hr)

Duration: limit to first 24-48 hours after disease onset

Tenner S, et al. American College of Gastroenterology guideline: management of acute pancreatitis. Am J Gastroenterol 2013;108:1400-15.Buxbaum JL, et al. Early aggressive hydration hastens clinical improvement in mild acute pancreatitis. Am J Gastroenterol2017;112(5):797-803.

Pain Control

Don’t be afraid to use IV opiates (PCA is okay)

• Hydromorphone

• Fentanyl

• Good safety profile in renal impairment

• Meperidine

• Short half-life, so repeated doses → neuromuscular side effects

• Morphine

• ? Increase in Sphincter of Oddi pressure

Nutrition

Early refeeding (when severe pain, nausea, vomiting resolves)

• Low-fat soft or solid diet is safe and provides more calories than a CLD with advancement to solids

Enteral vs parenteral feeding (after 3-5 days)

• Enteral feeding is recommended in patients with moderately severe or severe pancreatitis

• Lower mortality

• Lower rate of multiorgan failure

• Lower rate of infection and need for surgical intervention

• Shorter length of hospital stay

Vaugh VM, et al. Early versus delayed feeding in patients with acute pancreatitis: a systematic review. Ann Internal Med 2017;166(12):883.Jacobson BC, et al. A prospective, randomized trial of clear liquids versus low-fat solid diet as the initial meal in mild acute pancreatitis. Clin Gastroenterol Heptaol 2007;5:946-51.Al-Omran, et al. Enteral versus parenteral nutrition for acute pancreatitis. Cochrane Database Syst Review 2010;1:CD002837.

Antibiotics

2010 Cochrane Review• 7 studies included• 404 randomized patients• NO statistically significant effect on reduction of mortality with

therapy

Prophylactic antibiotics are NOT recommended in acute pancreatitis regardless of type (interstitial, necrotizing) or severity (mild, moderate, severe).

Antibiotics should be given for any extrapancreatic infections or infected necrosis.

Jafri N, et al. Antibiotic prophylaxis is not protective in severe acute pancreatitis: a systematic review and meta-analysis. Am J Surg2009;197:806-13.Villatoro E, et al. Antibiotic therapy for prophylaxis against infection of pancreatic necrosis in acute pancreatitis. Cochrane Database SystRev 2010;5;CD002941.

ERCP

Useful in gallstone pancreatitis or superimposed cholangitis

Indications for ERCP

• Acute cholangitis (high fever, WBC, or sepsis)

• Total bilirubin > 5.0 mg/dL or a rising bilirubin

• Persistent pain and obstruction

• Severe pancreatitis

American College of Gastroenterology. ERCP: A Patient’s Guide. Accessed Jan 2018. http://patients.gi.org/topics/ercp-a-patients-guide/

Cholecystectomy

Mild pancreatitis

• Early > delayed cholecystectomy

• Ideally during the same hospital stay to minimize costs and reduce risk of recurrent pancreatitis

Severe pancreatitis

• Early cholecystectomy = higher mortality

• Delayed cholecystectomy (within a few months)

• Allow time for pancreatic inflammation to diminish

Da Costa DW, et al. Same-admission versus interval cholecystectomy for mild gallstone pancreatitis (PONCHO): a multicenter randomisedcontrolled trial. Lancet 2015;386:1261-8.

Surgical Interventions

Pseudocysts, pancreatics necrosis, extrapancreatic necrosis

• If asymptomatic, NO intervention regardless of size, location, extension

Infected necrosis

• Surgical, radiologic, or endoscopic drainage after 4 weeks

• Minimally invasive necrosectomy > open necrosectomy

MKSAP QUESTION

Question 1

A 35-year-old man is evaluated in the emergency department for a 6-hour history of epigastric abdominal pain that radiates to the back. He also has nausea and occasional bilious vomiting. He has consumed between six and twelve beers daily for 10 to 15 years.

On physical examination, temperature is 37.2 °C (99.0 °F), blood pressure is 110/65 mm Hg, pulse rate is 105/min, and respiration rate is 22/min. Abdominal examination discloses epigastric tenderness without guarding or rebound. Bowel sounds are present but hypoactive, and there is mild abdominal distention. No jaundice is noted.

Question 1

Laboratory studies reveal a leukocyte count of 14,000/μL (14 ×109/L), a blood urea nitrogen level of 25 mg/dL (8.9 mmol/L), and a serum lipase level of 952 U/L.

Abdominal ultrasound shows a normal-appearing gallbladder and no biliary dilation. The patient is admitted to the hospital. Over the next 48 hours, he has ongoing abdominal pain, nausea, and poor appetite despite supportive therapy consisting of pain medication and aggressive intravenous fluid replacement. Subsequent contrast-enhanced CT of the abdomen shows nonenhancing areas of the head and body of the pancreas (consistent with necrosis) and several peripancreatic fluid collections.

Question 1

Which of the following is the most appropriate management?

A. Drainage of the fluid collections

B. Endoscopic retrograde cholangiopancreatography

C. Enteral nutrition by nasojejunal tube

D. Total parenteral nutrition

CASES